Petition Child Abuse Severe Abuse Repeated Abuse {10-7}

F.C.A. §§ 1012, 1031 Form 10-7 (Child Protective - Petition--Abuse, Severe Abuse or Repeated Abuse ) (8/2010) FAMILY COURT OF NEW YORK COUNTY OF ............................................................................ In the Matter of Docket No. CIN # (A) Child(ren) under Eighteen Years of Age Alleged to be Abused by PETITION [Check applicable box(es)]: Child Abuse Severe Abuse Repeated Abuse Respondent(s) ............................................................................ NOTICE: IF YOUR CHILD STAYS IN FOSTER CARE FOR 15 OF THE MOST RECENT 22 MONTHS, THE AGENCY MAY BE REQUIRED BY LAW TO FILE A PETITION TO TERMINATE YOUR PARENTAL RIGHTS AND MAY FILE BEFORE THE END OF THE 15-MONTH PERIOD. IF SEVERE OR REPEATED ABUSE IS PROVEN BY CLEAR AND CONVINCING EVIDENCE, THIS FINDING MAY CONSTITUTE THE BASIS TO TERMINATE YOUR PARENTAL RIGHTS. IF THE PETITION IS GRANTED, YOU MAY LOSE YOUR RIGHTS TO YOUR CHILD AND YOUR CHILD MAY BE ADOPTED WITHOUT YOUR CONSENT. TO THE FAMILY COURT: The undersigned Petitioner respectfully alleges that: 1. Petitioner [specify]: is a [check applicable box]: duly authorized agency having its office and place of business at [specify]: person directed by the Court to originate this proceeding, who resides at [specify]: 2. The child(ren) who (is) (are) the subject(s) of this proceeding (is)(are): Sex Date of Birth Custodial Parent/Guardian Child's Address1 Name 3. a. (Upon information and belief) The father and mother of the child(ren) and their respective residence addresses are: Unless ordered confidential, pursuant to Family Court Act §154-b, because of a risk that disclosure would place the health, safety or liberty of the child at risk. American LegalNet, Inc. www.FormsWorkFlow.com 1 Form 10-7 Page 2 Name of Child(ren) Name of Parent Parent's Address2 b. (Upon information and belief) The person(s) legally responsible for the care of the child(ren) (is)(are) [specify]: who reside at 3 4. a. (Upon information and belief) The child(ren) (is) (are) abused on the following grounds and based upon the following facts [Specify grounds of child abuse under Family Court Act §1012, as well as supporting facts]: b. (Upon information and belief) The following Respondent (s) [specify]: , the [specify relationship]: of the child(ren), (is)(are) the person(s) who (is)(are) responsible for the abuse of the child(ren). 5. a. (Upon information and belief (s) The child(ren) (is) (are) also neglected on the following grounds and based upon the following facts [Specify grounds of child neglect under Family Court Act §1012, as well as supporting facts]: b. (Upon information and belief) The following Respondent (s) [specify]: , the [specify relationship]: of the child(ren), (is)(are) the person(s) who (is)(are) responsible for the neglect of the child(ren). 6. a. [Applicable in cases in which severe abuse is alleged]: (Upon information and belief) The following Respondent(s) [specify]: committed the following act(s) of severe abuse against the following child(ren) [specify children), act(s), including Penal Law section(s), if applicable, dates, locations, criminal convictions and other facts]: b. [Applicable in cases in which repeated abuse is alleged](Upon information and belief) The following Respondent(s)[specify]: committed the following act(s) of repeated abuse against the following child(ren) [specify child(ren), acts, including Penal Law section(s), if applicable, dates, locations, prior findings of child abuse and other facts]: 2 3 See footnote 1. See footnote 1. American LegalNet, Inc. www.FormsWorkFlow.com Form 10-7 Page 3 7. [Required if removal has occurred or is requested; check applicable box(es)]: a. Q (Upon information and belief) On [specify date]: , the following child(ren)[specify]: (was)(were) temporarily removed from the care of the following Respondent(s) [specify]: on the basis of the following facts and for the following reasons [specify]: in accordance with [check applicable box]: Q a court order pursuant to Family Court Act §1022, issued on [specify]: Q consent of the following Respondent(s) [specify]: obtained on [specify date]: pursuant to Family Court Act §1021.4 Q on an emergency basis without a court order pursuant to Family Court Act §1024. There was no time to obtain a court order because [specify]: b. Q (Upon information and belief) The child(ren) should be removed from the care of the following Respondent(s) [specify]: in accordance with Family Court Act §1027 in order to prevent imminent risk to the child(ren)'s life or health on the basis of the following facts and for the following reasons [specify]: 8. [Required if removal or continued removal of children is requested]: a. (Upon information and belief) Continuation in, or return to, the child(ren)'s home would be contrary to the best interests of the child(ren) because [specify facts and reasons]: This assertion is based upon the following information [check applicable box(es)]: G Report of Suspected Child Abuse or Neglect G Case Record, dated [specify]: G Service Plan, dated [specify]: G The report of [specify]: G Other [specify]: , dated [specify]: b. (Upon information and belief) Reasonable efforts, where appropriate, to prevent or eliminate the need for removal of the child(ren) from the home [check applicable box and state reasons as indicated]: G were made as follows [specify]: G were not made but the lack of efforts was appropriate [check all applicable boxes]: G because of a prior judicial finding that the Petitioner was not required to make reasonable efforts to reunify the child(ren) with the Respondent(s) [specify date of finding]: G because [specify other reason(s)]: G were not made. This assertion is based upon the following information [check applicable box(es)]: 4 A copy of the consent instrument must be attached to the petition. See F.C.A. §1021. American LegalNet, Inc. www.FormsWorkFlow.com Form 10-7 Page 4 G Report of Suspected Child Abuse or Neglect G Case Record, dated [specify]: G Service Plan, dated [specify]: G The report of [specify]: G Other [specify]: , dated [specify]: c. (Upon information and belief) Based upon Petitioner's investigation [Check applicable box(es]: The following person [specify]: is a non-respondent parent relative suitable person with whom the child(ren) may appropriately reside [specify]: [Applicable to relatives and other suitable persons]: Such person: seeks approval as a foster parent in order to provide care for the child(ren); wis